Classification of Nutritional Status in Children and Adolescents: Differences Between National and International Growth Reference Charts: A Systematic Review

Abstract

Abstract Background: The choice of growth reference is critical for classifying nutritional status in children and adolescents, with direct implications for clinical practice and public health surveillance. While international references from the World Health Organization (WHO), US Centers for Disease Control and Prevention (CDC), and the International Obesity Task Force (IOTF) offer standardised tools, their application across diverse populations can shift classifications. This review compares national and international growth reference charts to assess their effects on prevalence estimates of thinness, stunting, overweight and obesity, and implications for service planning. Methods: PubMed and MEDLINE (2010–2025) were searched using terms for growth references ('growth chart', 'growth standard'), anthropometry ('body mass index', 'height-for-age'), and comparison/agreement/misclassification to identify studies comparing National and International Growth Reference Charts in 5–18-year-olds. Primary outcome: prevalence differences; secondary: classification agreement. Eight studies met inclusion criteria and were synthesised narratively. Results: Choice of reference materially altered classifications across settings. In four of eight studies (Saudi Arabia, Slovakia, Italy, Iran), WHO classified more children as obese than the national charts; in two Indian studies, the IAP national reference yielded higher overweight/obesity than WHO/CDC. Overweight alone was frequently higher under national cut-offs in three studies (Saudi Arabia, Delhi, Chennai). Conversely, WHO classified more children as underweight in two studies (Saudi Arabia, Delhi), while one Iranian study reported higher underweight with the national curve and one Indian study found CDC yielded higher underweight/stunting than IAP. Agreement ranged from minimal to near perfect (κ = 0.31–0.97), generally stronger between structurally similar systems (IOTF–national) and weaker for WHO vs CDC or national charts. One study found WHO more sensitive for clustered cardiometabolic risk, while national/IOTF were more specific. Conclusion: Growth reference selection has practical consequences for referrals, resource allocation and national surveillance. For clinical decision making and local planning, contemporary, representative national charts are preferable, while dual reporting with an international system supports comparability. Services should standardise measurement protocols and provide clear guidance on the default clinical chart. Limitations: Evidence is cross-sectional, with heterogeneous cut-offs, uneven geographic coverage, inconsistent reporting of measurement protocols, and a lack of urban–rural data.